milc memos

Low milk supply seems to be a main concern for today's breastfeeding mother. I do remember mothers asking, "how will I know that my baby is getting enough?" and, "how much milk does my baby need?" back when my first child was born (19 long years ago). The difference I suppose was that we were satisfied with the answers we were given and we never pumped to see how much our body was presumably making. We relied on observing our baby. Today's mother seems to want more answers and to know exactly how much milk she is making. Here is a brief overview of Low Milk Supply.

When should we be concerned that our milk supply might be low?

Insufficient Weight Gain

Babies are expected to gain approximately one (1) ounce per day for the first two months and then half an (.5) ounce per day until around six months of age. Remember however that all growth charts are just guidelines to follow. They were developed to help monitor the growth and development of a large amount of babies especially in poor areas to watch for anything going wrong. Now we utilize them for every baby but often we put too much stock into those numbers instead of looking at the whole child.

Lack of bowel movements

The first several days of life a baby's bowel movements are what we call meconium. Usually by day four, the baby is transitioning to bowel movements that are lighter in color and moving towards yellow or brown and mustardy. If baby is still having meconium bowel movements at day five, you should contact your health care provider. During the first few weeks of life, a baby should have frequent bowel movements. If a newborn baby goes more than 24 hours without a bowel movement, you should contact your health care provider. After three weeks of age, the bowel movements may space out more. As long as baby is happy and healthy there is no cause for concern.

Lethargic Baby

Some babies are very relaxed. Relaxed and lethargic are quite different. We want to see a baby being "active and alert" at the breast when feeding. Your baby should be moving actively, looking around, making noises, etc. If your baby seems inactive or overly sleepy you may wish to contact your health care provider.

What can cause a low milk supply?Maternal Concerns*Note that the majority of maternal issues would be present from the onset of the breastfeeding relationship.

Breast Surgery

Breast reductions and augmentations would be the top of this list however biopsies, injuries and surgeries of other types fall into this category. If you have had any of the above at any time you should consult with your OB/GYN and an International Board Certified Lactation Consultant (IBCLC) to discuss how these may effect breastfeeding for you and what you can do to improve your chances of being able to provide a full or partial milk supply to your baby.

Insufficient Glandular Tissue (IGT)

These breasts have less milk making tissue and so mothers who have IGT may need to supplement.

Thyroid Problems

Can cause issues with milk release.

Diabetes

Milk production can be affected if insulin requirements are not well managed. Mothers who are diabetic can reduce their child's risk of developing both type 1 and type 2 diabetes in adulthood by breastfeeding.

Polycystic Ovary Syndrome & Other Fertility Issues

If a mother had issues preventing her from becoming pregnant without assistance these issues may also affect lactation.

Retained Placental Fragments

Can occur even after cesarean birth.

Breastfeeding Mismanagement

Most often IBCLCs find that milk supply has been reduced due to what we call breastfeeding mismanagement. This can mean that either baby was not being put to the breast often enough (early scheduling or sleep training) or baby was at the breast but with poor positioning and thus unable to nurse effectively.

Infant Concerns

Prematurity

Premature babies may be smaller or have weaker jaws and may need assistance transferring milk in the beginning. Usually these babies will become more efficient as they grow.

Oral Concerns

Tongue Tie and/or Lip Tie are the most common however there are other oral irregularities that can affect breastfeeding. Congenital malformations such as Cleft Palate and/or Cleft Lip can also make breastfeeding challenging and cause mom's supply to drop if baby is unable to nurse effectively.

Muscle and Neurological Issues

As with prematurity these babies may need help until they are able to develop their oral muscles more or may need continued assistance but can transfer a portion of their food at the breast. Remember that breastfeeding is more than food. The closeness and comfort for many babies will help them to grow and develop and provide comfort to both mom and baby.

Chromosomal Disorders

Down's Syndrome is among the most common. Many Down's Syndrome children are able to breastfeed with little assistance but perseverance from their amazing mothers.

Heart Conditions or other illness

These babies may be too weak to transfer milk effectively.

What can we do?With any of these concerns the first step would be to work with an experienced Health Care Provider (HCP). This can be your OB/GYN, Pediatrician and/or an International Board Certified Lactation Consultant (IBCLC). Who you work with depends on which issue you are dealing with. While seeking out a professional who can assist you and working on a care plan you will want to:

Make sure baby is being fed.

Make sure you are protecting your milk supply by pumping and/or hand expressing in addition to breastfeeding.

Ways to Increase Milk Supply

Increasing Milk Removal

Breastfeeding more frequently, pumping more frequently and in general increasing the removal of milk from the breast. Breast compressions may also assist with this.

Assist Baby in Gaining Oral Strength/Developing Orally

Working with an IBCLC you can develop a care plan to work with Pediatric Dentists, Pediatric Ear, Nose and Throat Doctors, Speech Therapists, Occupational or Physical Therapists, Chiropractors and/or Cranio Sacral Therapists to aid baby in gaining oral strength and function. By doing this you will find baby is able to stimulate your breasts to make more milk.

Bring Mother's Health into Balance

Your OB/GYN or other HCP can work with you to check maternal hormone levels, thyroid function, etc. to bring mother's health into balance to assist her body in being able to produce more breastmilk. This includes checking for retained placental fragments which must be removed.

Utilizing Galactagogues

Galactagogues are any substance that increases milk production. These include herbs, foods and prescription medications. A list of common galactagogues is below.

Human milk sharing has been around most likely since the beginning of time. When women died in childbirth another woman would step in to breastfeed her child. When one woman was away from her child another would breastfeed that baby in a sort of informal shared parenting agreement. There were no bottles or breastpumps. Other cultures still share breastmilk with each other as a way to survive. Even here in the United States situations can arise where mothers are unable to provide breastmilk to their baby themselves but wish for their baby to receive the nutrition of breastmilk and so they enter into some sort of human milk sharing.

There are two basic types of human milk sharing. Those are formal and informal milk sharing.

Formal milk sharing is done by utilizing milk obtained from a Milk Bank. Milk Banks are facilities that collect human milk donations, batch process the milk and pasteurize it before sending it to families in need.

Informal milk sharing is the sharing of breastmilk from one mother to another. There are websites set up for milk sharing but often it is done via word of mouth or local area mothering groups.

Formal Milk Sharing

Formal Milk Banks in the United States are usually members of the Human Milk Banking Association of North America (HMBANA). Milk Banks are non-profits and generally serve a region of the country. There are currently 15 milk banks serving the entire United States. You can find information about how the breastmilk is processed here. Donors to milk banks are screened and fill in detailed questionnaires to weed out any potential donors who are taking medications, supplements, etc. that could effect the babies who receive their milk. Because of the expensive screening process milk banks only take donations of a certain quantity to be most cost effective. The milk from these formal milk banks is usually available by prescription only and goes to the babies who are most in need first. This milk generally is shipped to hospitals for premature or ill babies whose mothers can not provide breastmilk to them. The breastmilk is seen as medicine for these babies and is very important for their survival. We at The MILC Group strongly encourage any mamas who have extra stored breastmilk or who have the desire to assist these families to contact a local milk bank and donate that breastmilk! The closest milk bank to us is the Mother's Milk Bank Austin. There are collection sites set up in San Antonio and other cities that will ship your milk to Austin to be processed. The Mother's Milk Bank in Austin ships milk to many other states that do not have their own milk banks. They are such an amazing resource!

Informal Milk Sharing

Informal milk sharing is not as structured. There are safety concerns regarding the use of breastmilk not obtained from a milk bank. This breastmilk comes from a mother who you may or may not know. You are not necessarily aware of her health history, what medications she takes, what her diet is like and whether or not she consumes drugs or alcohol. Many mothers who share their milk are actually willing to provide proof of their good health. They will also inform the mothers that they share their milk with of their diet and medication use. One of the national groups set up for informal milk sharing has some guidelines on screening potential donors. You can find those guidelines here. There are a number of national and international organizations set up to assist mothers in sharing their breastmilk with those in need. Here is a list of a few:

Here at The MILC Group we as International Board Certified Lactation Consultants (IBCLCs) uphold very strict health standards. We promote breastfeeding and support mothers in reaching their breastfeeding goals. We provide information and resources. However, we do not facilitate milk sharing or act as a go between for mothers. There are risks to milk sharing. A great discussion of these risks can be found in this article, ﻿Milk sharing and formula feeding: Infant feeding risks in comparative perspective? by Karleen D. GribbleandBernice L. Hausman.﻿

Nipple shields....are they good or a bad? There is so much conflicting information out there for moms so we thought we might try to clarify it.

Nipple shields have been used in one form or another for over 500 years! Early nipple shield were made of:

Silver - Can you imagine your baby latching on to a silver nipple cover??

Wood - Ouch...watch for splinters!

Lead - We all now know the dangers of this material to brain development.

Pewter - Similar in texture to the silver and must have tasted terrible.

Animal skins - Probably the softest and maybe the most helpful.

Ivory - Very high class but very rigid and I wonder how hard they must have been to make. Poor elephants!

Fast forward to the 20th Century and we started to make nipple shields from rubber, latex and now silicone. They have come a long way for baby and are much thinner now than ever before.

We hear a lot about the possibility of nipple shield use reducing milk transfer. This most likely comes from a 1980 study which had this finding. The thing is that the nipple shields being used in 1980 and those being used today are quite different. The much thinner silicone shield allows for much more feeling for mother and thus less reduction in milk transfer and production. Some shields also have a cut out for the babies nose and this tends to aid in that touch component.

We recently asked a group of moms why they used a nipple shield and these were some of their responses (paraphrased):

We used it for a few days when baby wouldn't latch. I think it kept baby at the breast.

My baby was premature and it helped him to latch. We then found a tongue tie once he was bigger. We were able to stop using the shield once it was clipped.

We tried the nipple shield due to a tongue tie but my baby didn't like it.

I used a nipple shield because my nipples were flat/inverted at first. We weaned off around 3 months. I wish we had tried sooner.

I had flat nipples and the shield helped my baby to latch.

My nipples were very damaged and the shield helped my nipples to finally heal. We used the shield for several months but now have weaned from it.

Why Use a Nipple Shield?﻿Nipple shields can be a great tool if used with common sense. Good reasons include:﻿

Flat or Inverted Nipples - Many moms have no clue that their nipples are flat or inverted until they have a baby. A shield can assist with early latching. Note: Some babies have no trouble with latching on a flat or inverted nipple!

Premature Baby - Nipple shields are commonly used for these babies who struggle to latch. The shield is often the only way that these babies can maintain suction. They can be a tool that saves this breastfeeding relationship.

Babies who prefer the bottle - When baby has been given a bottle in the hospital and is sent home not nursing a nipple shield can feel closer to a bottle nipple in baby's mouth and can help to transition baby back to the breast.

Damaged Nipples - Some mommas have nipples that really take a beating in the early days of breastfeeding. A nipple shield can be just enough of a barrier to help mom heal her nipples for a few days to get baby back to directly nursing.

Tongue Tie - Some families choose not to revise a tongue tie. A nipple shield can be the only way that baby will nurse until their mouth gets larger/stronger or until their tongue does stretch a bit. (There are lots of schools of thought here. Not offering an opinion just a reason for the shield use).

Ultimately, there are usually underlying circumstances for which a nipple shield is being used. It is imperative that families visit with a trained lactation professional to figure out what is going on and to make sure that we take care of those issues. Long term nipple shield use may be a challenge. Often babies will not take a nipple shield as they get older. Carrying a nipple shield with you at all times can be stressful and putting one on with ease before latching baby in public can also cause mom undue stress.

This is not going to be a popular post for some of you. Others of you may cheer and be happy that I am saying it. This post is brought on by the massive numbers of mothers who discuss pumping on breastfeeding support pages and in breastfeeding groups. Let me clarify that YES, working mothers will need to pump in order to provide milk to their baby and to maintain their milk supply while they are away from their baby.

Let's look for a moment at the History of the Breastpump....

Ancient Greeks and Romans used different ceramic or glass containers to catch or extract breastmilk.

Breastpumps were first invented in the mid-19th Century.

The idea of the breastpump was taken from the dairy industry....go figure.

Breastpumps were first invented for use by mothers who had inverted nipples or who had babies that were too weak to breastfeed.

The modern in-home electric breastpump has only been in use for about 24 years.

Medela created its first hospital breastpump in 1980.

1983 Medela's handpump was put on the market.

1991 Medela starts selling it's mini-electric breastpump.

An amazing invention, the breastpump allows women to work away from their babies and to provide milk for them with much more ease than in the past. Our foremothers had to work very hard to provide milk for their babies if they were away working.

Good reasons to use a breastpump:

For a premature or sick infant who is unable to feed at the breast.

To provide supplementary milk when baby is not able to take in enough on their own (a transfer issue).

To provide milk for your baby while you are working outside the home.

Inducing lactation for an adopted baby.

For drawing out nipples that are flat or inverted (if baby has trouble latching).

NOT good reasons to use a breastpump:

Relieving engorgement. Hand expression works wonderfully in removing engorgement without the hassle of pulling out the pump, washing it all before and after, etc.

To allow other family members to feed baby. There are so many other ways for the rest of the family to bond with baby. Feeding baby is not one of them. The time that baby is exclusively breastfed is so short. Soon baby will be starting solid foods and family can assist in feeding then.

To take a break from baby. Do mothers deserve a break? Yes, of course. But there are so many ways that partners and family can give momma a break that don't involve her having to pump for a bottle -- a long bath while someones takes baby for a walk (or at least stays on the other side of the house), a haircut (these don't take so long that baby will need a bottle), a walk alone (take your phone in case baby needs you), etc.

To create an emergency supply. When did this idea of an "emergency supply" surface?? I have known many women who have breastfed for many years and never had any milk stored up "just in case." Ultimately if an emergency situation happened, your family would either feed the baby formula for that hopefully short period of time (a good use for formula) or your dear friends that are breastfeeding might offer to donate breastmilk to you.

For mothers of multiples to feed baby. Since the beginning of time mothers of multiples have been able to provide milk for their babies at the breast. It definitely takes time and juggling, but it's also very empowering to meet the needs of multiples.

Maintaining a milk supply. Feeding baby at the breast whenever you are together is much more effective for maintaining your milk supply.

Donating milk to a milk bank or informally sharing breastmilk. This is such a worthy cause. HOWEVER, your baby should always come first. If pumping is taking time away from your baby or causing an oversupply (which could lead to plugged ducts and/or mastitis), then it is possibly not the right choice for you.

Ultimately, a breastpump is a tool that was designed to be used when you are AWAY from your baby, NOT sitting right in front of your baby. Too often we see mothers who are obsessed with their pumping output instead of concentrating on just relaxing and feeding their baby. We look at the numbers on the outside of a bottle or milk storage bag and judge ourselves and how much milk we can release from our bodies. Stop judging your body. Nurture your milk supply by nursing your baby early and often from birth and then on demand as baby grows. If your baby shows signs of not taking in enough food (low weight gain, low diaper output or dehydration), seek the assistance of an experienced International Board Certified Lactation Consultant (IBCLC) and your Health Care Provider.

In the last few days I have been answering lots of questions on the La Leche League USA Facebook page as well as my local LLL of San Antonio Facebook group. It seems the majority of the questions are centered around milk supply. Not a big shocker really. It seems in this day and age mamas are always concerned about their milk supply. Their baby can be super chunky, having a pee diaper every couple of hours and pooping up a storm, yet they are still worried.

The modern nemesis of all lactation support people is.....the lactation cookie! I see posts all the time on IBCLC and La Leche League Leader pages venting their frustration that the answer to every breastfeeding malady seems to be the lactation cookie. I am right there with them.

I was only able to pump three ounces at my last sitting what can I do?......just eat some lactation cookies and your supply will skyrocket. (No mention that three ounces is a great amount to have pumped and a full feeding for a breastfed baby is two to four ounces.)

My breasts don't feel as full as they used to......just eat some lactation cookies and you will instantly feel fuller. (No mention that all mamas stop feeling "overly full" after their supply is established around three months for most mothers.)

My baby has a tongue tie and I don't want to get it revised but I want to increase my supply.....just eat some lactation cookies and it will all be better. (If that baby has a tongue tie and is unable to nurse effectively, increasing her supply will only lead to plugged ducts and mastitis since baby can't empty breast effectively.)

Do you see what I'm saying? The lactation cookie can only do just so much. How can you increase your milk supply for real?

Breastfeeding your baby frequently with a proper latch is the best way to increase your supply. Look at how often you are feeding baby. If you are scheduling feeds, consider allowing baby to feed on demand or decreasing the time between feedings.

If baby's latch is not great, getting some help to work on that will make things much better. So many mamas don't go back to their hospital lactation center after baby is born, but a visit there could make a world of difference.

Learning more about lactation such as how your breasts work, how much to bottle feed a breastfed baby, how much and how often to pump, etc. will relieve many of your fears.

Stop stressing. Stress can decrease your supply.

Stop listening to well-meaning family and friends that are making your doubt your milk supply.

If you do all of the above and still want to eat some lactation cookies, go ahead. Enjoy a cookie :)

Most babies will lose weight after they are born. We like to say that babies are born "juicy" and so weight loss is normal. A study published in the December 2014 issue of Pediatrics (the Official Journal of the American Academy of Pediatrics) confirms this. The study is authored by Dr. Flaherman of the University of California, San Francisco, and her colleagues.

In this era of induction and cesarean births we are seeing babies with higher weight loss percentages than in years past. Having worked in lactation for over 16 years I have seen these expected percentages change over the years. In the 1990's a 7% weight loss was what was considered "normal." Somewhere along the way it became 10%. I now consistently see babies losing 10% and sometimes more. My colleagues and I work with mothers who are on IV fluids, pitocin and epidural drips for 24 hours or more. That is a lot of fluid being taken on by the mother and in turn the baby. A few days after an induced or cesarean birth the mother usually finds her legs are swollen up like tree trunks and her feet won't fit into anything but flip flops. Where do we think these fluids go for baby?

According to the authors of the study of the 108,907 exclusively breastfed newborns, 83,433 were delivered vaginally and 25,474 were delivered by cesarean. "Differential weight loss by delivery mode was evident 6 hours after delivery and persisted over time. Almost 5% of vaginally delivered newborns and >10% of those delivered by cesarean had lost ≥10% of their birth weight 48 hours after delivery. By 72 hours, >25% of newborns delivered by cesarean had lost ≥10% of their birth weight."

We regularly tell parents that their pediatrician will expect their baby to be back up to "birth weight" at the two week appointment. We will see if this study will change these guidelines or if they will stay the same. Either way we at The MILC Group will continue to support the families of our community in feeding their babies.

I could probably write twenty or more blog posts on this topic alone. Milk Supply seems to be the main concern of most modern day mamas. This morning I got a call from a mama of a very new baby who was concerned about her breastmilk supply. Why was she concerned?

Her Mother keeps questioning her about whether or not baby is getting enough.

She pumped yesterday and only got a few ounces of breastmilk so her supply must be low.

Her husband told her that they should just go ahead and put the baby on formula since they don't know how much breastmilk baby is getting at a feeding.

What did I NOT hear during the phone call?

That baby is losing weight or not gaining adequately.

That baby isn't having enough wet or poopy diapers.

That baby seems fussy at the breast at every feeding.

That mama has a physical condition that could lead to a low supply.

Nope, not one of these possible low milk supply signs was voiced by this mama. This call was mended fairly easily by reassuring this first-time mama that her baby sounds as though he is doing well.

I was able to point out that:

Her baby is having plenty of wet and poopy diapers.

Her baby eats well at the breast and falls asleep easily at the end of a feeding.

The mama was able to pump 4 ounces in one sitting (even though I have now advised her not to pump when baby is so young).

Baby is gaining weight well.

Baby is active and alert when awake.

I made a few suggestions for this mama:

That she bring her own mother with her to a breastfeeding support group meeting.

That the mama let her husband and mother know that she needs them to be supportive and to not question breastfeeding so much.

That she trust in her own maternal instincts.

Now if only this mama had more support around her on a day-to-day basis....I hope she finds some breastfeeding friends soon!

Thankfully, our community here in San Antonio, Texas, has a good number of breastfeeding support groups as well as a burgeoning natural parenting community. Studies show time and again that women who have access to breastfeeding support groups have higher long term breastfeeding success. We at The MILC Group are committed to growing and supporting our local breastfeeding community. Here are a few good reasons to attend a breastfeeding support group:

Prenatally

See "real" baby behavior

Hear what other new moms are asking

Get a visual on what breastfeeding looks like

Start to grow your network of support

Postpartum

Get all of those early questions answered in person

Feel supported in your decision to breastfeed

Meet other breastfeeding mothers with babies close to your baby's age

Nurse in a relaxed atmosphere while enjoying some good conversation

Learn about what to expect "down the line"

Continuing

Enjoy a network of breastfeeding families

Continue to receive support from your community on your journey

Create life-long friendships

The MILC Group is expanding our offerings to the community. We will be hosting a weekly Breastfeeding Support Group! Here are the details:

From the French & Michigan website, "Turning to the politics of breastfeeding, Sudhoff pulls from her inability to produce enough milk for her then-young son as inspiration for documented performances, milk typologies, self-portraits, and sculpture. The milk serves as subject and metaphor for feelings of loss and failure experienced by so many mothers, while highlighting the way in which breastfeeding is highly medicalized and undeniably personal in contemporary American culture."

Thank you to all the mothers who came out with and without their babies. We would also like to thank Celeste Wackenhut who has so beautifully curated this exhibit and brought us into the project and Elizabeth Pearson who is the most amazing chef we know and provided the delicious treats we enjoyed that morning. Most of all thank you to Sarah Sudhoff for this beautiful work!